Prime Minister’s Awards for Teaching Excellence



Prime Minister’s Awards for Teaching Excellence and Teaching Excellence in STEM

2018 Nomination Form

All personal information collected in the nomination package is protected under the Privacy Act. It is used by Industry Canada to process the nominations and for related statistical studies. Participation is voluntary. Information will be stored in Personal Information Bank IC PPU 001. Nominees may access, request correction of, or have a notation attached to the information about them by contacting the Prime Minister’s Awards (PMA) Office at 613-991-4255 or ic.pmate-ppmee.ic@canada.ca. Each award recipient’s name, school, community, school representatives, and work contact information may be included in short biographies published for the media and online.

Nominee's Personal Information

□  Dr.   □  Mr.   □  Mrs.   □  Miss □  Ms.

Last Name _______________________First Name _______________________ Maiden Name _______________________

Home Address _______________________________________________________________________________________

City______ _______________________ Province/Territory _______________________ Postal Code __________________

Telephone (Home) ___________________________ E-mail (Home) ____________________________________________

Telephone (Work) ____________________________ E-mail (Work) ____________________________________________

Is the nominee a Canadian citizen or permanent resident? □ Yes   □ No

At the time of nomination, does the nominee teach a minimum of 2.5 days per week? □ Yes   □ No

At the time of nomination, does the teacher hold a valid teaching certificate? □ Yes   □ No

Is this a team nomination? □ Yes   □ No

Does the nominee self-identify as Indigenous? □ Yes   □ No

What grades and subjects does the nominee teach?

Grades ____________________________________________________________________________________________

Subjects ___________________________________________________________________________________________

Is this a nomination for the Prime Minister’s Awards for Teaching Excellence in STEM? □ Yes   □ No

(The candidate must teach at least one STEM related subject to be eligible)

Nominator Information

□  Dr.   □  Mr.   □  Mrs.   □  Miss □  Ms.

Last Name __________________________________________ First Name ______________________________________

Address ____________________________________________________________________________________________

City________ _______________________ Province/Territory ______________________ Postal Code _________________

Telephone (Home) __________________________________ Telephone (Work) __________________________________

E-mail __________________________________________ Do you want to receive email updates? □ Yes   □ No  

Relationship to the nominee: □ Principal/Vice-principal   □ Colleague   □ Parent   □ Student   □ Other

Principal/Supervisor Information

□  Dr.   □  Mr.   □  Mrs.   □  Miss □  Ms.

Last Name __________________________________________ First Name ______________________________________

Telephone (Work) ________________________________ E-mail (Work) ________________________________________

Was this nomination written by the nominee’s principal/supervisor? □ Yes   □ No  

Nominee's School Information

School Name (or school board if teacher is not affiliated with a particular school)

___________________________________________________________________________________________________

Address ____________________________________________________________________________________________

City____ ___________________________ Province/Territory _____________________ Postal Code _________________

Telephone _________________________ E-mail_________________________________ Facsimile __________________

Website ____________________________________________________________________________________________

Social Media ________________________________________________________________________________________

Is the school a First Nations school? □ Yes, on reserve   □ Yes, off reserve   □ No

School Board Information

School Board Name __________________________________________________________________________________

Contact Person_________________________________________Telephone ____________________________________

Facsimile ________________________ E-mail_____________________________________________________________

Website ___________________________________________________________________________________________

Signatures

Nominator

I, the nominator, hereby affirm that all the information contained in this nomination package is, to the best of my knowledge, complete and correct and that the nominee upholds the highest standards of the teaching profession.

Signature of Nominator __________________________________________ Date ________________________________

Nominee

I, the nominee, hereby affirm that, to the best of my knowledge, all the information contained in this nomination package is complete and correct. By signing this form, I authorize the Prime Minister’s Awards office to conduct a verification of the information provided in this nomination package. I understand that the best teaching practices of national level Prime Minister’s Award recipients may be published online and I give my release for that purpose should I be chosen for this award. I also consent the use of my photographs for promotional and information materials by the Prime Minister’s Awards. I have read the Prime Minister’s Awards recipient Code of Conduct found on the program website and understand that failure of abide by these standards, if chosen, could result in the revocation of this award.

Signature of Nominee ___________________________________________ Date _________________________________

Principal/Supervisor

I, the principal/supervisor, affirm that all information contained in this nomination package is, to the best of my knowledge, complete and correct. By signing this form, I, the principal/supervisor, confirm that I have read and support this nomination.

Signature of Principal/Supervisor __________________________________ Date _________________________________

Submitting your nomination by email

Before submitting your nomination by email, make sure you meet the following requirements:

• Your files are saved in one of the following formats: .pdf, .doc, .docx .rtf, .txt, .jpg, .jpeg, .tiff, .tif, .xps.

• The total file size of your nomination does not exceed 10MB

• Your email is sent no later than the nomination deadline

• You submit your nomination electronically to: ic.pmate-ppmee.ic@canada.ca

Submitting your nomination by mail

Before mailing your nomination, make sure you meet the following requirements:

• Your nomination is postmarked no later than the nomination deadline

• Your nomination is mailed to the following address:

Prime Minister's Awards

Innovation, Science and Economic Development Canada

C.D. Howe Building

235 Queen Street

Ottawa, Ontario K1A 0H5

For more information, please contact the Prime Minister Awards at 613-991-4255 or ic.pmate-ppmee.ic@canada.ca.

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